Present and Future Mustafa CETIN MD December 2016 Erciyes University BMT Center KHUH Doctor Education Program Passweg et al BMT Feb 2016 ASCT in Europe 2014 ID: 774718
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Slide1
Autologous Stem Cell Transplantation Present and Future
Mustafa CETIN, MD December, 2016
Erciyes University BMT Center
KHUH , Doctor Education Program
Slide2Passweg et al. BMT Feb 2016
ASCT in
Europe (2014
Survey)
Slide32
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H S C T
P
CD
NHL,HD,CLL
ST
Leukemia
N
MD
Main
Indication
ASCT
3
ASCT in
Europe (2014
Survey)
Slide4Passweg et al. BMT Feb 2016
ASCT in
Europe (2014
Survey)
Slide5Cumulative Plot of Transplant Recipients in the US by Transplant Type
Cumulative plot of transplant recipies in
the US by transplant type
Slide6Trends in Autologous Transplants by Recipient Age*
Trends in Autologous Transplants
by Recipient Age
Slide7Indications for Hematopoietic Stem Cell Transplants in the US, 2013
Indications of Hematopoetic Stem Cell
Transplants
İn
the US, 2014
Slide8Adult
Pediatric
Hematopoetic Stem Cell Activity
in TURKIYE, 2000-2012
Annual increase in HSCT, 2000-1012
Teams
/
Centers
, 2012
Slide9Hematopoetic Stem Cell Activity
in TURKIYE, 2008-2012
Adult
Pediatric
Totally
Slide10Today’s Topics
Autologous HSC Transplantation
Evident
based
History for LLM
Transplantation Procedures
Pre-transplant assessment
General eligibility criteria for Auto-HSCT
Disease Related Indications & Outcomes
Improving outcomes
of
ASCT
Pre-transplant induction
therapies
High-dose chemotherapy
regimens
Post-transplant maintenance
treatments
Improving tolerability of
ASCT
Stem cell
dose
Growth
factor
support
Prophylactic
therapy
Expanding
eligibility
to
ASCT
Auto-Transplant in elderly
patients
Slide11First Response to The Autologous-BMT
Slide12Hematopoietic Stem Cell Transplantation for Hodgkin Lymphomas:
Schmitz et al, Lancet
2002
TX
Slide13Hematopoietic Stem Cell Transplantation for Diffuse Large B Cell Lymphomas:
DHAP
and if PRRandomizationAuto-BMTMore DHAP
Relapsed DLBCL (n=109)no previous bone marrow infiltration
TX
Slide14Hematopoietic Stem Cell Transplantation for Multiple Myeloma:
A significant survival advantage of high-dose chemotherapy (HDC) and auto-HCT over conventional chemotherapy was reported in the pivotal IFM trial in 1996
As
CONCLUSION:High-dose therapy combined with transplantation improves the response rate, event-free survival, and overall survival in patients with myeloma.
TX
Slide15IFM 94
: Overall survival
P < 0.01
Tandem
Single
A
u
t
hor
No. Pts
RR (%)
EFS mos.
OS mos.
Attal et al, NEJM 2003
399
42 vs 50* (p=NS)
25 vs 30 (p=0.03)
48 vs 58 (p=0.01)
Single versus Tandem Auto-SCT,
P <
0.001
MM del(17p) and/or t(4;14) and not CR after
Hematopoietic Stem Cell Transplantation for Multiple Myeloma:
TX
Slide16Autologous Haematopoietic Stem Cell Transplantation
General wiev to Auto-SCT
Autologous HSC
Transplant
Procedure
Slide1717
What are
the Hematopoetic Stem Cells?
Autologous HSC Transplant Procedure
General wiev to HSCT
Slide18Bone Marrow
Peripheral Blood
18
Cord Blood
Sources of Stem
Cells
Autologous HSC
Transplant
Procedure
General wiev to HSCT
Slide19Autologous HSC
Transplant
Procedure
Stem Cell
Sources
Slide20What
do we need to consider
pre
Auto-
HSCT?
Patient
IssuesStem Cell SourceSuitable BM (Remission?)Source of Stem Cell(BM,PB,) What is the CMV status?
Patient
Issues
Other:
Smoking
AlcoholOther recreational drugs
Patient IssuesComorbidities & RisksEBMT risk score (Age,PS,etc)Clinical Elgibility criteriasComorbidity index HRCT-CI,
Patient IssuesWhat does the patient want?To make an informeddecision they need to be fully informed
Disease
issuesIndication statusChemo-sensitivity Dis.Alternative Treatments Life Expectancy Urgency
Patient
Issues
Social
Circumstances
What
level of support
do
they
have
?
Dependents
Distance
from
Hospital
Finance
Slide21PRETRANSPLANT ASSESSMENT (Clinical)
● Age — The initial studies that demonstrated a benefit from auto-HCT were performed in younger adults (<65 years), subsequent studies suggest that the benefit from auto-HCT is also seen in older adults.●Detailed history – While all elements of the patient's history are pertinent, issues particularly relevant to potential complications include: performance status prior therapies, drug allergies (especially to antibiotics), and prior infections. ●Physical examination with particular attention to the oral cavity, for example for abscesses or tooth decay (a potential source for infection to treat prior to auto-HCT), and central nervous system.●Laboratory studies include complete blood count with differential, chemistries with liver and renal function and electrolytes,24-hour urine collection for the measurement of creatinine clearance (especially in patients with multiple myeloma),● Electrocardiogram & ECHO or MUGA, Chest radiograph & Pulmonary function test, including DLCO
A pretransplant assessment must establish the extent of disease and provide information about the individual's comorbidities that are likely to have an impact on outcomes,
Autologous HSC Transplant Procedure
General eligibility criteria for autologous hematopoietic cell transplantation
Slide22General eligibility criteria for
autologous hematopoietic cell transplantation
Seropositivity for HIV does not exclude patients from undergoing auto-HCT
DLCO: diffusing capacity of the lungs for carbon monoxide.
PRETRANSPLANT ASSESSMENT (Laboratory)
Autologous HSC
Transplant
Procedure
Slide23Autologous HSC
Transplant Procedure
For treatment of hematologic malignancies,
Patient’s Bone marrow must be uninvolved by tumor cellsPatient must be able to tolerate high dose chemotherapyautologous transplantation is only indicated if patient has chemotherapy sensitive disease
Slide2424
De Clercq E. The bicyclam AMD3100 story. Nat Rev Drug Discov 2003; 2: 581–587
MP Rettig, G Ansstas and JF DiPersio. Leukemia. 2011 Sep 2. doi: 10.1038/leu.2011.197
-Stem Cell Mobilization Agents & Mechanisms
Autologous HSC Transplant Procedure
Extracellular matrix
osteoblast
KL VCAM-1
CXCR4
HSC
CD62L
Kit
VLA-4
SDF-1
CD62
osteoblast
CD44
HA
Extracellular matrix
Prelifaxor
HSC
mobili
s
ation
NE CG MMP9
G-CSF
PMN
osteoblast
KL VCAM-1
CXCR4
HSC
CD62L
Kit
VLA-4
SDF-1
CD62
osteoblast
CD44
HA
Extracellular matrix
GCSF
adhesive interactions between HSC and BM:
cell adhesions molecules
Pruijt
,
Fibbe
et al. 1999; Hattori et al. 2002
AMD 100
Slide25Filgrastim (G-CSF ) (Success rate: 70-95%) Multi-step interactions in the marrow microenvironment lead to stem cell mobilization.
Pain, headaches, arthralgias, malaise, fatigue, insomnia, and nause, Transient increase in ALP, ALT, LDH, Na and transient decrease in potasium, spontaneous splenic rupture Increased spleen size in length (in 95% of pts) (mean increase,13%) but 10 days after G-CSF administration, spleen size returns to baseline.
10
11
12
13
14
1
2
3
4
5
6
7
8
9
G-CSF
10
-25
mcg/kg day
,
BID
CD-34
+
Start
leukaphaeresis
on day
4,
5
Minimum number of CD34+ cells: 2 x 10
6
/kg
circulating
CD34 + cells gradient> 20 / ϥL
G-CSF
Slide26(G-CSF & Chemo) (Success rate: 70-95%).
Mostly use in chemosensitive cancer patientsNot only mobilise HSC but also eradicate tumoral massSolid tumors, Lymphomas, Leukemias, and MyelomaCy Treatment may also treat Autoimmune Disease
CY
10
11
12
13
14
1
2
3
4
5
6
7
8
9
G-CSF
CD-34
15
16
17
18
19
1
2
3
4
5
(Cy+ G-CSF
)
Cy
:
4gr/m2
and
GCSF :
10-25
mcg/kg
G-CSF &
Chemo
Slide2727
De Clercq E. The bicyclam AMD3100 story. Nat Rev Drug Discov 2003; 2: 581–587
MP Rettig, G Ansstas and JF DiPersio. Leukemia. 2011 Sep 2. doi: 10.1038/leu.2011.197
Reversible inhibitor of the CXCR4/CXCL12 axisA single subcutaneous dose of plerixafor at 160–240 μg/kg: 6- to 10-fold increase in CD34+ cell, Typically administered in conjunction with filgrastimSide effects include abdominal discomfort, leukocytosis, potential for splenic rupture (rare)
Plerixafor (Success rate: 70-80%) after any failure
Prelixafor /AMD-100
Slide28Mobilised
Autologous Stem Cells Removed from patients
patients
APHERESIS PROCESS
FOR The autologous
GraftAT LEAST 2X106. CD34 /KGOPTIMUM 5X106. CD34 /KG
Apheresis Procedure
Stem Cell Mobilization and Collection
Autologous HSC
Transplant
Procedure
Slide29Cytotoxic
Chemotherapy
RIC Allo for GVL
MAC Auto for Tumoral Eradication
MAC Allo for BM Ablation
Biol Blood Marrow Transplant.
2009 Dec; 15(12): 1628–1633.
Bacigalupo,
Results in reversible
myelosuppression
(usually within 28 d) when given without stem cell support
Dose & Response Curve with
Cytotoxic
Chemothrapy
TUMORAL CHEMOSENSITIVITY
Conditioning Therapy
Autologous HSC
Transplant
Procedure
Slide30The first stage of the transplant. May be given in one dose or over several days. ........................................................Necessary for:Destroying remaining cancer cellsCreating room in the bone marrow for the transplanted stem cells......................................................................................Conditioning regimen is dependent on the type of disease, the type oftransplant, co-morbidities and age.
30
Conditioning Therapy
Autologous HSC
Transplant
Procedure
Slide31At
least 24 hour after the conditioning will be given on Day 0. These are generally given through a central line and takes approximately 30 minutes. Stem cells are either cryopreserved or fresh.CryopreservedUsually for autologous transplantsMost common side effects are reactions to DMSOFreshUsually for allogeneic transplantsAdministered much like a blood transfusionGenerally better tolerated than frozen cells.
Stem Cell Re-infusion
Autologous HSC
Transplant
Procedure
Slide325
15
20
0,5
x
10
9
/
L
Neutrophils
Conditioning
In
f
usion of graft
10
d
a
y
s
Stem cell
transplantation
The stem cells of the
donor
have been taken up by the patient´s bone marrow (”have engrafted”)
The first of three days with neutrophil count> 0.5 x 10⁹/L
Definition of engraftment
D
ay, 12
ENGRAFTMENT
Autologous HSC
Transplant
Procedure
Slide33First of three consecutive days with the indicated blood cell levels:Neutrophils > 0.5 x 10⁹/LLeucocytes > 1.0 x 10⁹/LPlatelets (without transfusion) > 20 x 10⁹/LPlatelets (without transfusion) > 50 x 10⁹/LWithout transfusion: no transfusions for at least seven days before reconstitution is recorded
Haematopoietic Reconstitution
Thomson
B G et
al. Blood 2000;96:2703-2711
ENGRAFTMENT
Autologous HSC
Transplant
Procedure
Slide34Autologous hematopoietic cell transplantation (auto-HCT) is most commonly performed for the management of patients with Hematologic MalignaciesMultiple myeloma, Non-Hodgkin lymphoma, Hodgkin lymphoma.Solid Tumors, Autoimmune Diseases There are no accepted guidelines regarding indications for auto-HCT and recommendations regarding indications for auto-HCT differ between transplant centers [1].
DISEASE-RELATED INDICATIONS
Autologous HSC
Transplant
ation
Slide35● Acute myeloid /Lymphoid leukemia – As post-remission therapy in patients in first remission. ● Hodgkin lymphoma – Treatment of chemotherapy-sensitive relapsed disease. ● Diffuse large B cell lymphoma – Treatment of chemotherapy sensitive relapsed disease. ● Waldenström macroglobulinemia – Treatment of chemotherapy sensitive relapsed disease. ● Follicular lymphoma – Treatment of chemotherapy sensitive relapsed disease or clinically progressive /aggressive Ds ● Peripheral T cell lymphoma – As consolidation therapy in first CR or for the treatment of sensitive relaps ● Multiple myeloma – As consolidation therapy following initial response to CT or relapsed / refractory Ds● Mantle cell Ly – As consolidation therapy in first CR or for the treatment of chemotherapy sensitive relapsed Ds ● AL amyloidosis – As consolidation of initial response to CT or for the treatment of relapsed Ds
In general, auto-HCT may be considered in the following settings:
DISEASE-RELATED INDICATIONS
Autologous HSC
Transplant
ation
Slide36Early complications: DMSO TOXİCİTYMyelosuppressionNausea, vomiting, diarrheaMelphalan-induced arrhythmiasFebrile neutrpenia, sepsisMucositisLate complications:BCNU pneumonitisMyelodyspastic syndromeInfertility and other endocrine abnormalities
Majority of complications are related to side effects of high dose chemotherapy
Complications of ASCT
Autologous HSC
Transplant
ation
Slide37Survival after Autologous Transplants for Hodgkin Lymphoma, 2003-2013
Survival after Autologous Transplants
For Hodgkin Lymphoma, 2014
Treatment of chemotherapy-sensitive relapsed disease.
Slide38Survival after Autologous Transplants for Follicular Lymphoma, 2003-2013
Survival after Autologous Transplants For Follicular Lymphoma, 2014
Treatment of
Ch sensitive relapsed Dis. or Clinically progressive /aggressive Ds
Slide39Survival after Autologous Transplants for Diffuse Large B-cell Lymphoma (DLBCL), 2003-2013
Survival after Autologous Transplants For Diffuse Large B-Cell Lymphoma, 2014
Treatment of
chemotherapy sensitive relapsed disease.
Slide40Survival after Transplants for Mantle Cell Lymphoma, 2003-2013
Survival After Transplants For Mantle Cell Lymphoma, 2014
As
consolidation therapy in first CR or for the treatment of chemotherapy sensitive relapsed Ds
Slide41Survival after Autologous Transplants for Multiple Myeloma, 2000-2013
Survival after Autologous Transplants For Multiple Myeloma, 2014
As
consolidation therapy following initial response to CT or relapsed / refractory Ds
Slide42Today’s Topics
Autologous HSC Transplantation
Transplantation Procedures
Pre-transplant assessment
General eligibility criteria for Auto-HSCT
Disease Related Indications & Outcomes
Improving outcomes
of
ASCT
Pre-transplant induction
therapies
High-dose chemotherapy
regimens
Post
-transplant maintenance
treatments
Improving tolerability of
ASCT
Stem cell
dose
Growth
factor
support
Prophylactic
therapy
Expanding
eligibility
to
ASCT
Auto-Transplant in elderly
patients
Slide43What is the major determinant
of outcome?
General Survival Of Hematopoietic Cancers
Extermann M et al. Eur J Can 2000;36:453 Havlik R et al. Cancer 1994;74(s7):2101
Slide44Causes of Death after Autologous Transplants done in 2012-2013
Causes of Death after Autologous
Transplantation done in 2012-2013
Slide45ASCT outcomes are improved by induction with novel drugs(proteasome inhibitors and immunomodulatory drugs).Adverse cytogenetic features such as t(4;14) and deletion 17p were overcome.French 2005-01: VD produced higher CR/nCR, VGPR and ORR compared to VAD.These response rates remained higher post ASCT with a trend to a better 3-yr PFS in the VD arm (36 mo. vs 30 mo., p=0.064).Spanish Myeloma Group: induction with VTD was superior to TD orconventional chemotherapy with added bortezomib.CR rates favored VTD both post induction (35 vs 14 vs 21%) and post ASCT (46 vs 24 vs 38%), translating into:mPFS in the VTD arm of 56 vs. 36 vs. 28 mo. (p=0.01).
Pre-transplant induction therapies in Multiple Myeloma
Barlogie et al. Blood 2014;124:328
Improving outcomes
of
ASCT
Pre
-transplant
Therapies
Slide46Intergroupe Francophone du Myélome (IFM): phase III VTD to VD.VTD induced higher VGPR rates (50% versus 36%, P = 0.047) but identical CR rates (14 versus 12%)This improvement persisted after HDT (VGPR or better: 66 versus 54%, P = 0.044)HOVON- 65/GMMG-HD4: induction with VAD followed by ASCT and T maintenance vs. PAD followed by ASCT and maintenance with B.CR rates were superior after PAD (31vs 15%; p<0.001) and B maintenance (49 vs. 34%; p<0.001).B during induction and maintenance abrogated the deleterious effect of del17p on both PFS and OS. Conversely, B may not always overcome the deleterious effect of deletion 17p in the non-transplant setting.
Pre-transplant induction therapies in Multiple Myeloma
Improving outcomes
of
ASCT
Pre
-transplant
Therapies
Slide47ICE vs DHAP (CORAL): similar outcomes.
Crump et al. JCO 2014;32:3490
Gisselbrecht et al. 2012;30:4462GDP vs DHAP (LY12): GDP is associated with:noninferior response ratesimilar transplantation rate, EFS, and OSless toxicity and hospitalizationsuperior quality of life
Pre-transplant induction therapies in non-Hodgkin’s Lymphoma
Improving outcomes
of
ASCT
Pre
-transplant
Therapies
Slide48: Non Hodgkin Lymphomas
Isidori et al. World J Stem
Cells
2015;7:1039
Improving outcomes
of
ASCT
High-dose
C
hemotherapy
R
egimens
Slide49High-dose chemotherapy regimens: Hodgkin’s
Isidori et al. World J Stem
Cells
2015;7:1039
Improving outcomes
of
ASCT
High-dose
C
hemotherapy
R
egimens
Slide50GIMEMA: VTD vs TD administered pre- and post-tandem ASCT5-yr PFS favored VTD (62 vs. 49%; p=0.045).(n)CR rates favored VTD (73 vs. 61%; p=0.02)The Nordic Myeloma group: bortezomib vs. placebo as consolidation for 5 cycles.PFS post ASCT 27 vs 20 mo. (p=0.05).Thalidomide: 8 randomized studies, all showing improved PFS withimproved duration of disease control.In three 3 studies an OS benefit emerged.However, T induced peripheral neuropathy that adversely affected QoL.
: Multiple Myeloma Consolidation and maintenance with novel drugs improves outcomes of ASCT.
Barlogie et al. Blood 2014;124:328
Improving outcomes
of
ASCT
Post-transplant
Maintenance
Treatment
Slide51IFM 2005-02 study: lenalidomide maintenance improved the VGPR rates from 76 to 84% (p=0.009) and improved mPFS from 23 mo. with placebo to 41 mo. with LEN (p=0.009), without difference in OS.The CALGB 1001004 study randomized patients to lenalidomide or placebo post ASCT. LEN maintenance improved: mTTP: 50 vs 27 mo. (p<0.001)OS: not reached with LEN vs 73 mo. with placebo (p=0.008).
Barlogie et al. Blood 2014;124:328
: Multiple Myeloma Consolidation and maintenance with novel drugs improves outcomes of ASCT.
Improving outcomes
of
ASCT
Post-transplant
Maintenance
Treatment
Slide52:In our handsPre-transplant induction therapies: triplet including a novel drug (VCD x4).High-dose chemotherapy regimens: No innovation yet (MEL200 for MM and BEAM for lymphoma)Post-transplant consolidation and maintenance treatments in MM:High-risk and less than CR: second ASCTAll other patients: 2x VCD, then LEN for 18 month if less than sCR:
To
i
mprov
e
outcomes
of
ASCT
Slide53Today’s Topics
Autologous
HSC
Transplantation
Transplantation
Procedures
Pre
-
transplant
assesment
General eligibility criteria for
Auto
-HSCT
Disease
Related
Endications
&
Outcomes
Improving
outcomes of
ASCT
Pre-transplant induction
therapies
High-dose chemotherapy
regimens
Post
-transplant maintenance
treatments
Improving tolerability
of
ASCT
Stem cell
dose
Growth
factor
support
Prophylactic
therapy
Expanding
eligibility
to
ASCT
Transplant
in
elderly Multiple
Myeloma
patients
Slide54Doses >5x106 CD34+ cells/kg are associated with:Faster neutrophil recovery.Higher median platelet counts or faster platelet recovery.Improved DFS and OS.Reduced resource utilization and cost of care.>5x106 CD34+/kg has been regarded as the ideal dose, while >2x106CD34+/kg represented the minimal cell dose.A retrospective analysis of 2 randomized trials assessing Plerixafor confirmed better platelet engraftment dynamics and less platelet and red cell transfusions for the >5 million dose.
Duggan, et al. BMT. 2000;26:1299 - Siena JCO 2000;18:1360 - Sola et al. Hematology. 1999;4:195 - Kiss et al. BMT 1997;19:303- 310 - Schwella et al. JCO 1996;14:1114 - Blystad et al BJH 2004;125:605 - Toor et al. BJH 2004;124:769 - Limat et al. Eur J Cancer 2000;36:2360 - Schulman et al. JCO 1999;17:1227Stiff et al. BBMT 2011;17:1146
Improving
tolerability
of
ASCT
Stem Cell
Dose
Slide55Granulocyte colony-stimulating factor (G-CSF) is used after peripheral blood ASCT to further accelerate neutrophil engraftment.The result is a small but significant reduction of:Number of febrile daysI.V. antibiotic useDuration of hospitalizationCosts.Delaying the beginning of G-CSF from d1 to d5 or 7 post-ASCT, produce a small delay of neutrophil recovery that may not translate into a significant increase of duration of fever, i.v. antibiotic use, or days spent in hospital.Pegfilgrastim is a slow clearance formulation of filgrastim administered as single dose.
Hornedo et al. BMT 2002;29:737 - Klumpp et al. JCO 1995;13:1323 - Lee et al. BJC 1998;77:1294 Linch et al. BJH 1997;99:933 - Schmitz et al. BMT 1995;15:26 - Valteau-Couanet et al. BMT 2005;36:547 - Bence-Bruckler et al. BMT 1998;22:965 - Bolwell et al. BMT 1998;21:369
Improving
tolerability
of
ASCT
Growth
factor
support
Slide56Today’s Topics
Autologous HSC Transplantation
Transplantation Procedures
Pre-transplant assessment
General eligibility criteria for Auto-HSCT
Disease Related Indications & Outcomes
Improving outcomes of
ASCT
Pre-transplant induction
therapies
High-dose chemotherapy
regimens
Post
-transplant maintenance
treatments
Improving tolerability of
ASCT
Stem cell
dose
Growth
factor
support
Prophylactic
therapy
Expanding eligibility to
ASCT
Auto-Transplant in elderly
patients
Slide57Expanding eligibility to ASCT
Transplant in elderly Multiple Myeloma patients
Ozaki et al. Biomed Res Int
2014
Slide58Day 100 MortalityFinland (> 60 years)11 %Mayo Clinic (≥ 60 years)5.4 %MD Anderson (> 65 years)4 %UCLA (> 70 years)17.7 %Nebraska (> 60 years)5.2 %Nice (>65 years)2.7 %Memorial SKCC (≥ 60 years)4 %
Jantunen
et al.
BMT 2006;37:367 // Buadi et al. BMT 2006;37:1017 // Hosing et al. Ann Oncol 2008;19:1166 Andorsky et al. BMT 2011;46:1219 // Martin et al. Leuk Lymphoma 2015 Feb 20:1-9 // Dahi et al. BBMT 2014;20:2004-9
HDCT
in the elderly with
lymphoma
Slide59Improving outcomes of ASCT
Multidimensional geriatric assessment (MGA):MM limit age 70, extended to 75 after favorable MGA.Lymphoma limit age 65, extended to 70 after favorable MGA.
Slide60Hematopoietic SCT for Hematologic Malignancies inElderly: Geriatric Principles in the Transplant Clinic
Few studies exist evaluating ASCT in patients > 65 years.No studies in patients > 75 years.Most studies were confined to MM and lymphoma.Elderly patients mobilize adequate numbers of stem cells.Comorbidity risk factors associated with poor outcomes. in older adultsElderly patients may display a modestly higher risk for specific toxicities and TRM, but older adults tolerate the procedure reasonably well.ASCT displays a similar effectiveness in older and younger adults.Prospective studies are needed.
Wildes et al. J
Natl Compr Canc Netw
2014;12:128-36
51
Slide61What is the major determinant
of outcome?
General Survival Of Hematopoietic Cancers
Extermann M et al. Eur J Can 2000;36:453 Havlik R et al. Cancer 1994;74(s7):2101
Slide62Any Questions?
62
Thank
you!
Slide63Hematopoietic cell transplantation-
C
omorbidity index (HCT-CI) scoring systems
Sorror
ML
et
al.
Cancer 2008;112:1992 Sorror
ML
et
al.
J Clin
Oncol
2008;26:4912
Slide64What is the major determinant
of outcome?
64
Hematopoietic cell transplantation-
C
omorbidity
index (HCT-CI) scoring systems